Rob Waters (RW): Manu, Governor Deval Patrick recently announced the next phase of the Mass HIway Health Information Exchange. What’s been your role in the preparations for the launch and what new tools will providers and other stakeholders now have access to?

Manu Tandon (MT): The new enhancement to the Mass HIway will enable participating providers to query, locate, and retrieve patient records. It is important to note that Massachusetts has taken an ‘opt in’ approach, meaning that patients must provide consent to their health care organization to publish their relationships to Mass HIway. Our aim over the coming years is to assist participating organizations with the consent process and populate the Relationship Listing Service in order to make this valuable for the healthcare community at large. We see this as a cornerstone technology to enable the administration’s policy goal of reducing costs and enhancing quality in the health care system in Massachusetts. As to my role, working with a very talented team, I have led the development and operations of Mass HIway.

RW: Many state HIEs are now looking at value added tools including reporting and advanced analytics that will support the development of ACOs and primary care coordination, is this a direction that Mass HIway is also be taking?

MT: Our approach to the HIE is that we see it as a safe and secure conduit that connects several nodes. Sort of like a mailman with security. While providing advanced analytics services does not directly fall in the box of being a conduit, we certainly see such services being added as nodes on the HIE. We encourage public and private solutions that provide this service to connect to the Mass HIway. For instance on the Medicaid side, we are working on a project to attach a Quality Data Repository (QDR) and Quality Analytics solution to the Mass HIway. I think the question is less about our ability to transmit and capture quality data and more about the electronic health record’s ability to produce quality data that is programmatically relevant for ACOs. I think we need to move beyond Meaningful Use on this account.

RW: Data privacy and security agreements is always a challenge when introducing new services to healthcare stakeholders, were there any new measures that were introduced along with the latest service rollout at the exchange?

MT: Massachusetts is ‘opt in’ so additional patient consent must be obtained and documented for use of Query and Retrieve, which encourages a meaningful dialogue between patient and provider on privacy and security. Most organizations in Massachusetts already have experience obtaining patient consent so for the most part, the community has been learning from each other.

There are several elements that greatly enhance the security of the Mass HIway over traditional methods of sending and receiving personal health information, such as fax, mail, or usb drive. These elements include message encryption end to end so messages can only be read by the intended recipient, built in audit logs to track users who have accessed a patient’s relationship list, and user authentication through unique IDs and strong passwords. It’s important to note here that the Mass HIway does not store any personal health information. Storage of health records remains with the patient’s institution. All participants of the Mass HIway sign an agreement to comply with all security and privacy requirements required by law, and patients can speak with their healthcare providers to discuss security measures in place at the site level.

RW: You’re also responsible for the coordination of HIT for Medicaid and other human services agencies in Massachusetts, will this next phase of implementation at the Mass HIway impact any of the other programs you’re involved with?

MT: The goal is to bring state agencies into better alignment on healthcare quality metrics and related data so key agency programs can rely on consistent, actionable information and providers can avoid sending the same information to multiple agencies. The Mass HIway will serve as a mechanism to improve quality measurement data collection and reporting across the state and within our health and human services agencies. Health information technology offers tools to support pay for quality programs and health care innovations to drive the next phase of health reform- improving quality while controlling costs. In addition, Mass HIway will deliver a provider directory solution that we intend to leverage for other health and human services programs in Massachusetts.

RW: In your own personal vision for the Mass HIWAY, what excites you about the future potential for the role of the exchange in 5 years from now?

MT: As a citizen, I am tickled by the possibility of healthcare data liquidity with full privacy and security controls for better health outcomes. As an executive, I am convinced that our vision is the right one and am satisfied with the fiscal, technical, programmatic, and stakeholder alignment we deeply enjoy in Massachusetts. The manager in me though knows that we are not there yet. We have much work to do over the next 5 years as we continue to work with electronic health record vendors and participating health care organizations to bring the full value of the Mass HIway to fruition. By building upon the success of over 65 live participants, 1.8 million transactions that have traversed the Mass HIway, and leveraging the success of our early adopters of Query and Retrieve, we look forward to making the Mass HIway the ubiquitous, seamless solution it is envisioned to be in Massachusetts. I remain strongly optimistic that this tool will play a key role in making a real impact on patient health outcomes and lowering costs in the health care system. In the end, that is what drives us.

Jim Wadleigh, CIO, Access Health CT (Connecticut’s Health Benefits Exchange (HIX)) sat down with Healthcare IT Connect‘s Rob Waters to discuss the launch of the exchange, emerging trends from the first months of enrollment, how data from the exchange will be used to optimize the marketplace and how Access Health CT is planning to share technology and lessons learned with other states.

Rob Waters (RW): Jim, it’s now been over 3 months since the launch of Access Health CT, how did the launch go and what how has progress been with enrollments at the exchange to date?

Jim Wadleigh (JW): The launch went very well other than some periodic issues with the Federal Data Services Hub. Although the Fed’s have been working through their issues, these issues did impact Connecticut consumers. The enrollment progress has been great and proceeded as expected; had an initial flurry, a lull, and then the mad rush for the end of December for enrollment for the first of January. The current enrollment is nearing 90,000, a leading state for being head of our Federal target enrollment.

RW: Could you give me some insights into the day of a life of a HIX CIO and some of the challenges you’re facing during the early days at the exchange?

Every day is hectic even with a great launch. Daily, stakeholders think of things they need to include in the solution. It can be anything from a new data element to a new business rule to handle something that was initially not included or new functionality to accelerate enrollment of applications.

JW: From the early data you’ve seen coming out of the exchange, what have been some of the identified trends and have there been any surprises?

Trends1. Individuals wait until the last day and last hours to complete the application.2. Individuals require more than one web-site visit to finish the process for the selection of a plan (think time).3. Terminology matters. Since the on-line application is based on the Streamed Line Application some of the terminology is eligibility based vs. buy language.4. Individuals need assistance with terminology and the details in the application process.

SurprisesThe impact of the volume of enrollments to the carriers.

RW: How will Access Health CT be using the data to optimize carrier participation at the exchange?

JW: We have plans to roll out an All Payer Claims Database (APCD) in 2015 that will enable health analytics providing greater customer visibility to cost of care, quality of care, and access to care.

RW: Some HIX CIOs have referenced that sharing technology between different states has proven problematic, what was your experience been here and do you have any plans to share Connecticut’s technology and lessons learned?

JW: It is always difficult to share between any entities so sharing between states is no different. Some of it is interpretation of rules or laws and other is determining what components of the applications are part of the public domain. Though business rules, designs etc. can easily be shared, and have been shared, it is more difficult to share components of the system especially since a number of the states developed the solution on different platforms or used COTS solutions. The most challenges center around integration of a pre-existing solution. This also has the most cost impact.

Connecticut’s state-based exchange is developing an “exchange in a box” for other states that are interested in operating their own insurance marketplaces and don’t want to start from scratch with developing their own technology. This allows Connecticut to help empower other state-based exchanges that have experienced difficulty. Below are is an excerpt from one of the dozens of articles highlighting the success of the CT exchange. I’m proud to be leading such a great team!

“The state’s exchange is considered a model for the country because of its ease of use, Counihan (Kevin Counihan, CEO of Access Health CT) said. As a result, about 9% of state residents are uninsured, compared to about 17% nationally and as many as 30% or more in states like Texas, Florida and California.

The Connecticut exchange is simple, Counihan said. Users may log on to accesshealthct.com and, after confirming their eligibility, select from gold, silver and bronze plans offered by four health insurance providers.

Counihan said the web data shows that it takes about 40 minutes for a person to sign up, better than the national average of more than an hour.”

Health IT Veteran Scott Whyte recently made the transition from Dignity Health where he served as the VP IT Connectivity to his current role as the SVP for Growth and Innovation at ClearDATA, a leading supplier of cloud services to the healthcare sector. Scott has previously shared his insights from the provider perspective on solving complex interoperability challenges and implementing applications for coordinated care amongst multiple ACO participants. Healthcare IT Connect’s Rob Waters sat down with Scott to discuss his transition, how he came to work with ClearDATA during his tenure at Dignity Health and the challenges and opportunities CIOs face when they consider moving IT services to the cloud.

Rob Waters: Scott, you’ve recently made the transition from your role with Dignity Health as the VP of IT Connectivity to your current role with ClearDATA, how has the transition been so far?

Scott Whyte: It’s been a great transition. The care provider and solution provider roles are very complimentary. While at Dignity Health, I worked with ClearDATA on many innovative projects. Now that I’ve joined the ClearDATA team, I enjoy collaborating and working with healthcare executives in organizations of all types and sizes. I listen to their concerns, delve into their challenges and then share my experiences successfully achieving similar objectives. I’ve been in their shoes, there’s no substitute for that.

RW: In what capacity did you work with the ClearDATA platform at Dignity Health? How did this support your ability to support new care delivery models?

SW: Similar to most providers, I chose the ClearDATA cloud platform because it supported our focus on agility, security, and cost containment. It was my role to work with the hospitals and physicians at Dignity Health to quickly adopt new technologies and processes that would improve care in the community, guard patient data, reduce costs and establish a strong strategic position.
A great example of my work with ClearDATA related to the Clinical Integration of independent caregivers with the hospitals, enabling them to collaborate more effectively, measure care improvements and reduce cost.

RW: What are some of the common questions providers ask you when they are considering moving their data/services to the cloud?

SW: A few of the most common question are:

Where do we start?

What does it cost?

What are the benefits?

What are the challenges?

We’ve developed a consulting methodology that provides meaningful insight into a healthcare organization’s IT infrastructure, delivers pragmatic recommendations, and most importantly a roadmap for moving to the cloud. The complexities and costs of moving to the secure cloud are much less than most think. ClearDATA’s intense focus on healthcare and cloud technology has resulted in significant economies of scale.

RW: How do you see the cloud services segment evolving over the next five years and how do you envisage vendors services evolving to meet those needs?

SW: The healthcare cloud segment is exciting because we’re in the middle of rapid adoption and evolution. The demand is driven by a need to improve patient outcomes while containing or reducing costs. Moving to the cloud reduces healthcare IT costs (hardware, support, maintenance, etc.) while simultaneously improving infrastructure agility, performance and reliability. Initially we’ve seen EMR, billing and web apps move to the cloud. Over time, we’ll see imaging, big data, patient monitoring and genomics will move to the cloud to reduce implementation times and expensive upfront hardware costs.

RW:In terms of lessons learned during your time at Dignity Health what would be your one piece of advise to a CIO looking to migrate IT services to the cloud?

SW:Find the right project and the right partner and get started! It is a big win when a CIO can deliver improved speed to market, improved security and reduced cost.

The Center for Connect Health at Partners (CCH) recently launched Wellocracy, an independent online consumer resource for mobile healthcare apps, devices and activity tracking. Dr Jospeh Kvedar, Founder of the Center for Connected Health sat down with with HITC’s Rob Waters to discuss the inspiration, mission and launch of Wellocracy.com and the role of providers and wellness coaches in the mobile healthcare revolution.

Joe Kvedar: After working at remote patient monitoring for about 10 years, we were ready to bring self-care to consumers – couch potatoes, weekend warriors and all of us in between hoping to live a little healthier, lose a few pounds or just feel a little better. The goal of Wellocracy is at once simple and daunting – to get America moving, and to motivate our citizens to move to a healthier state. It turns out that the formula is straightforward: track your activity, find your individual set of motivational tools and find ways to increase your activity without disrupting your life.

Through our work at the Center for Connected Health, we saw that patients enrolled in our programs began to significantly improve their self-care, using their daily monitoring results to better understand their condition and understand how lifestyle choices affected their health.

As we observed this phenomenon, we broke it down into two sets of factors we could study: the use of objective data in feedback loops and the use of motivational psychology to help our patients strive to keep those data in the right range. Another profound, reproducible finding over the years has been the attachment patients feel for these home monitoring devices. This led us to the observation that self-tracking is contagious or in Internet parlance, ‘sticky.’ Most people enjoy seeing how their lifestyle affects some sort of number. Self-tracking keeps health top of mind and can keep people motivated.

As the quantified-self movement caught on to self-tracking and the deluge of self-tracking devices and apps that are now available came on the market, the time was right to bring these insights, this stickiness to consumers, to improve health and wellness in the population at large.

RW: How will Wellocracy’s mission of empowering consumers with information on ‘self health’ technologies be met?

JK: We start with the premise that the self-tracking market is crowded, confusing and oriented toward techies. Wellocracy is delivering up-to-date information, expert guidance, unbiased reviews and innovative ideas to get the most out of personal health technologies. Wellocracy is a source of impartial, easy-to-understand information on new personal “self-health” technologies like activity trackers, wireless devices and mobile apps to empower people to get and stay healthy. We believe that with insight and the right inspiration, we can learn from our own behaviors by harnessing simple technologies to engage in healthier lifestyles and activities. By integrating new health tools into daily life, we all have the ability to make positive changes and be more active. Wellocracy is focused on motivating each of us to be our best and healthiest selves.

RW: The majority of consumers have not yet utilized or had the opportunity to utilize a health tracking device. Do you see this as a set-back or an opportunity?

JK:We see this as a huge opportunity. There is a huge void in the market today. Easy to use, accurate and effective health and wellness trackers are readily available, yet most consumers are not using them. Wellocracy will fill that void and help individuals select the right health technology best suited to their preferences and goals, and figure out the personal motivation that will keep them on track to best manage their health. In fact, in a recent Harris Interactive survey commissioned by Wellocracy, we found that the majority of consumers (56%) have never used any type of health tracking device, app or website.

At the same time, this survey also found that 65% believe that using a health tracking device, website or app would be beneficial, including helping them stay motivated to meet health and fitness goals (32%), and over one-quarter believe it would provide accountability (31%) and help them stay in control of their health (27%).

We know that if we give people — young and old — insights into their health and help them understand how lifestyle choices impact quality of life, they feel more accountable, engaged and live a healthier, more active life. Integrating ‘self-health’ tools like activity and nutrition trackers and sleep monitors into our daily lives, we can learn from our own behaviors and make positive changes to take charge of our health. We’re taking these devices and apps, personalizing the experience and helping people figure out the right health technologies, the right strategy and the right inspiration to get on the right track to health and wellness.

JK:As healthcare professionals, we have to help empower patients to take control of their wellness, take responsibility for maintaining their health and, importantly, give people the tools to achieve this. A healthcare provider only has a very brief time with their patients, maybe a few times a year. Health and wellness trackers can serve as an extension of traditional care, create accountability, educate patients on ways toself-manage their health and provide important, real-time data for both patients and providers.

Providers can encourage patients or even ‘prescribe’ a tracker to monitor their health and ask that they share this data with them. We know that patients who track their health and wellness at home, and share that information with their providers feel better cared for, more in charge of their health and more satisfied with their provider.

RW:For healthcare providers who are looking at gaining meaningful insights from the coming wave of personal health data from mobile devices, what advice do you have and how can they avoid the pitfalls of becoming ”data rich, information poor”?

JK:It is important to establish decision support tools to manage patient derived data. This is an area very much still in development. It is fair to say that a provider without an EMR system would be hesitant to get too involved in collecting and evaluating patient self-reported data. But a few provider organizations and managed care groups are already offering to link patient data via an API. We will see this area evolve quickly, as the use of health trackers and mobile apps become more commonplace.

6. Are there lessons from the social media sphere that might help individuals and providers improve the value of personalized health data, how do you see these worlds intersecting in the future?

Healthy behaviors are not as easy to manipulate as, say, purchasing behaviors. But there is much we can learn from social media and ecommerce. I am developing the concept of ‘making health addictive’ using a series of strategies to delivering health and wellness messaging that is less clinical, less technical, less abstract and more focused on some aspirational, personal goal. Much like we now see with social media, if we put personalized, relevant, motivational and unobtrusive messaging in front of consumers, we can create permanent behavior change.

Every day, we leave an trail of online breadcrumbs that provide information such as activity level, GPS data, mobile purchasing data, natural language processing analysis of outgoing messages (tweets, texts, emails, etc.), which could be combined to give us a unique health-related profile. That will enable us to send individuals highly customized, personalized, relevant ads and messages every time you pick up your smartphone. Some of these messages will be so subtle you may not notice them. Some will be welcome and none of them will be annoying – if we do it right.

In addition, no one wants to appear unhealthy to our friends or family. Social networks will be a powerful tool to increase accountability and adherence to care, and wellness plans and mobile phones make social interactions that much more convenient.

Edward McGookin, M.D. is the Chief Medical Officer at Coastal Medical and is responsible for the oversight of all clinical activities at Coastal Medical as well as practice transformation towards Patient Centered Medical Home. Ed sat down with HITC’s Rob Waters to discuss the key components of Coastal Medical’s transformation process, the role of technology and some of the lessons learned from the HMO movement to wards delivering more accountable patient centered care.

Rob Waters: Why is patient satisfaction such an important part of the triple aim of accountable care organizations?

Ed McGookin:The reason for the primacy of patient satisfaction in the Triple Aim is that a focus on patient satisfaction addresses what has been lost in our fee-for-service model of health care. Our current health care delivery system does not provide consistent, high-quality medical care (National Research Council, 2001). The Centers for Medicare&Medicaid Services (CMS) has linked reimbursement to patient satisfaction. But the reason that patient satisfaction is such an important part of the Triple Aim is not that it is incentivized or mandated. The experience of institutions such as the Cleveland Clinic and the Mayo Clinic have shown that improving the patient experience of care can lead to substantial improvements in patient safety and quality of care (Merlino, 2013). Our health care delivery system must provide what patients need, not simply what science and technology can provide.

RW: With ACO’s stressing the need to move away from being data rich, but knowledge poor, how does Coastal Medical prioritize and meet more than 70 quality metrics?

EM: We quickly learned that until data is analyzed and represented in actionable formats, we simply have information rather than knowledge. All data sets include signals as well as noise and as an organization, we run the risk of interpreting noise as if it were a signal or failing to detect a signal amid the noise (Wheeler, 2000). Every organization works with finite resources and none can afford to use those resources inefficiently. Responding to data takes energy. We cannot afford the time or expense of implementing programs or process changes based on faulty interpretations of our data. It is imperative that we undertake change with a clear sense of why and how we will make those changes and what our intended outcomes will be.

Every organization that has tried to meet performance targets feels the sense of being made to “jump through hoops”. We constantly question whether the process changes we make really improve care or quality rather than simply fulfill a requirement that has no positive impact on outcomes. As an organization that has successfully performed on more than 70 quality metrics, we can honestly say that tracking performance and conscientiously responding to the data does in fact improve outcomes. As a pediatrician, I was mortified to see data that indicated my sexually transmitted infection (STI) screening rate in sexually active adolescents was less than 20%. I made all kinds of excuses and looked for all the possible flaws in the methodology for collecting the data. When we looked at the workflow processes in our office around STI screening we realized that the data was full of signals, but we had never looked or listened to them in the past. We changed our workflows and office standards around STI screening and within 6 months we improved our STI screening rates by more than 75%.

Electronic Health Records (EHR) provide health care organizations with an unprecedented ability to collect data. We have leveraged our EHR to collect data in structured data fields to facilitate reporting and responding to the opportunities to improve patient care or office processes. We have also realized that our EHR, like most EHR’s, was designed to receive and organize data, but that it was poor at producing actionable reports from the data we had entered. Coastal Medical employs four full-time data analysts who work to collect and report the data we use to inform the clinical program changes that we undertake. Despite the resources this team brings to our organization, we needed data analysis tools that could consume and aggregate our own EHR data, data from payers, and data from sources outside Coastal. We became a development partner with our EHR vendor to develop an analytics platform to meet our growing data analysis needs and are now beginning to use that data to inform our clinical programs.

RW: In your efforts to increase total cost transparency, what are some key strategies to effectively manage high-risk patient populations for the “sickest 5 percent”?

EM: Coastal has found that just has been stated by many other organizations, 5% of patients spend almost 50% of the healthcare dollars (Stanton, 2006). In our case, 6.2% of our patients account for 50% of our total cost of care. We began by referring to these patients as “high-opportunity” rather than “high-risk”. We realized that the patients in this demographic could benefit the most from care coordination. We developed interdisciplinary rounds or “care conferences” for this group of patients and have learned a great deal directly and indirectly from them.

Care conferences generally involve patients with poorly controlled chronic diseases or polychronic conditions. They are conducted in each office at least once weekly and involve the office manager, nurse care manager, clinical pharmacist and primary care physician (PCP). Often a representative from a home nursing agency that provides palliative and hospice care for our patients attends these conferences as well. Each member of the team reviews the chart records for the information relevant to their role in the care of the 15-20 patients who will be discussed in the one hour conference. Issues such as appointment no-show rates, last exam, emergency department utilization, hospitalizations, sub-specialty engagement, laboratory screening, polypharmacy, medication adherence, narcotic utilization, fall risk, advance directive status, and gaps in care are presented to the PCP who synthesizes the information and develops an action plan with the team.

Some of the insights from these care conferences have included the importance of patient engagement and ensuring that care plans are genuinely patient-centered. We have been reminded of the importance of taking the time and effort to understand what the enabling and motivating factors are in a patient’s care as well as the barriers to care are for an individual patient. Operationally, the value of effective pre-visit planning for office visits has been demonstrated repeatedly through these conferences. The impacts of behavioral determinants of health have prompted us to develop an integrated behavioral health program. We have seen a significant increase in the quality of care when patients are involved in our disease management programs. Our utilization of hospice care increased from 114 admissions in 2012 to more than 500 admissions in 2013. This is another example in which measuring and responding to performance data improves performance and quality of care. Finally, these care conferences have illustrated the importance of having a prospective means of identifying patients for care coordination and our data analytics now incorporates predictive modeling capabilities.

Post-acute care is an area where there is a great deal of variation in practice standards that result in unnecessary expenditure, duplication or delays in services, poor communication and risk for readmission. We have developed a Transition of Care clinical pathway and implement this for every patient leaving the hospital or a skilled nursing facility. Ensuring a safe and effective transition of care is one of the primary roles of our Nurse Care Managers.

RW:By distributing the workload of closing gaps in care for patients that have proven to be difficult to engage with, what are some of the best practices you’ve taken note of? What works? What doesn’t?

Patients who are difficult to engage with are often patients whose wishes are not in alignment with those of their caregivers. This is where the challenge of truly patient-centered care is contrasted to physician-centered care. Patient-centered care is a dimension of quality and transparency and individualization of care is imperative in a patient’s experience of care (Berwick, 2009).

“Every system is uniquely and perfectly designed to produce the results it is currently producing” (Senge, 1990). Our work in closing gaps in care has given us much clearer insight into the work flow and clinical processes that enable those gaps. The best practices we have observed include previsit planning, preappointment lab testing, expanding the roles of office staff and medical assistants in rooming patients and facilitating medication reconciliation and improving team functioning through lean process workflow redesign.

What doesn’t work? Asking physicians to do “one more thing”. There is already too much going on in the one-to-one encounter with the patient to add anything else. Physicians are spending too much time after a patient encounter or at the end of a day of seeing patients. EHR’s in their physician-centric designs have excelled at redistributing work to physicians. Very often this is work that can and should be done by other office and clinical professionals. We are looking toward innovative ideas such as scribing and assistant order entry as new ideas to consider (Sinsky et al., 2013).

RW: Given the speed at which the culture of healthcare is being asked to change, what are some of the lessons that can be applied from the HMO movement of previous years?

EM:Physicians who practiced in an HMO model before joining Coastal remark that we look more like a HMO as our ACO evolves. We have visited Kaiser-Permanente and have met with leaders in other clinically integrated organizations to learn from their experience in population health management. These interactions have reinforced the importance of providing care when patients need it and we have responded by ensuring access to care on weekends, holiday and evenings.

In order to take responsibility for the care of a population of patients we must engage the patients who need care or care coordination whether they engage with us or not. We use our data capabilities to identify the patients who need to come in for care or need a reminder for screening laboratory or imaging studies. We have learned the value of telephonic care particularly when the healthcare provider on the phone is introduced by a patient’s physician as a colleague and a valued member of the patient’s healthcare team. The emphasis on a team of healthcare providers made up of office staff, physicians, nurses, nurse care managers, and pharmacists has differentiated the experience of care for Coastal patients. It is inspiring when individuals proudly relate their experiences as Coastal patients in public discussions about the changing healthcare system.

Utilizing Technology to Meet the Needs of a Changing Healthcare SystemUtilizing eCW since 2006, Coastal Medial was an early adopter of technology specifically designed to improve patient care and reduce medical errors. The record has done all of this and much more. Currently, Coastal is using technology to reinvent the payment model for their ACO by utilizing the new CCMR functions. This new tool will enable the group to review data in real time and modify patient management strategy to reach even more of their goals which center around improving the patient experience and quality of care they provide, as well as reducing the cost of care across their entire population of patients.

Learning Objectives

Learn how the quality of data impacts ACO goals of “Triple Aim” Learn how access to quality data impacts P4P programs and work with specialty providers Learn why patient satisfaction is a main focus as medicine changes.

Bill Beighe, CIO, Santa Cruz Health Information Exchange sat down with HITC’s Rob Waters to discuss the delivery of HIT/HIE services to a diverse group of stakeholders in rural Santa Cruz County helping them participate in new care delivery models and also how the California Association of HIEs (CAHIE), a group of as many as 30 HIEs are collaborating on Statewide health information exchange efforts. Bill has been the CIO with Santa Cruz Health Information Exchange since 1998.
Rob Waters: Santa Cruz Health Information Exchange is recognized as one of the oldest and most advanced Health Information Exchanges (HIEs) in the country, what’s been the secret to your success?

Bill Beighe: We launched as a multi-stakeholder HIE and were funded from the beginning by member contributions, and we are sustained by monthly member contributions. Everyone has skin in the game and they only pay if they receive value. Providers follow the data and we work hard at constantly bringing more data and more connections into the HIE. Beyond results delivery and transitions of care one of the biggest satisfiers is a longitudinal patient record so that users, with the appropriate patient consent can gain access to care delivered across the many unaffiliated entities in our HIE.

RW: Independent physician practices, in may commentators view, face an uncertain future as the ACA is fully implemented, is this message being voiced by docs is the exchange helping physicians participate in new care delivery models such as ACOs and PCMH? Health Care Reform and Value Based Pay present a necessary but challenging transition that our providers need to navigate.

BB: We are part of 2 commercial ACO efforts and have been in long enough to show considerable progress. The HIE has been instrumental to helping make the ACO work however some of the early gains came about simply by collaborating on what workflow changes and what simple data we can we provide to make an impact. We are just beginning to scratch to surface on how the HIE can help improve care and reduce overall health costs. A number of our clinics are pursuing PCMH and the success of those efforts will rely of tight integration between the multiple EHR systems using of course the HIE. We are also planning on leveraging Direct, especially to include those members of the extended care team that do not have an EHR.

RW: Sustainability is often seen as major challenge to HIE, particularly those in rural areas. How is Santa Cruz charging for your services and how do you see this evolving over time?

BB: For the last 17 years, we charge a limited number of stakeholders a monthly fee for a set of services. We believe that all stakeholders need to pay based on the value received. I see the entire HIE / HIT market evolving to offering technology and services that go way beyond what we are doing today. Our solutions need to be measureable and offer real benefits of value to those that benefit from the service. Specific kinds of stakeholders vary from place to place depending on the mix of hospitals, the payer mix, large groups or IDN’s, IPA presence, Managed Care, etc. HIT/HIE service providers need to be treated more like physicians and subjected to getting paid for value. And be paid by the stakeholders that receive the value.

RW: California Health eQuality (CHeQ) recently announced the Rural Health Information Exchange Incentive Program, what’s this about and how will impact SCHIE and your participants?

BB: Our organization was awarded a contract to deliver HIE services to rural Californians along with 5 other HIE service providers. We intend to offer our expertise to rural organizations that can leverage our HIT and HIE offerings. Only one clinic in our home service area of Santa Cruz County was in the designated rural area and ironically that clinic already has a robust bi-directional connection with the rest of the providers in the SCHIE. We look forward to assisting providers in rural areas outside of Santa Cruz.

RW:The California Association of HIE’s (CAHIE) just arrived on the scene, can you tell us what this new organization is all about and how it is different from other efforts?

BB: This effort launched in March 2013 during an all-day problem solving session of a core group of HIE and IDN organizations from across the state. California being a large and diverse state already had numerous private and public HIE efforts up and running. Full disclosure, I am a co-chair for this group. Our mission is to enable safe secure data exchange ACROSS what appears to be as many as 30 HIE efforts, both private and public that are happening in California. We are leveraging NwHIN standards and have work groups working on DURSA adoption and testing the technical and policy implications of statewide exchange. We are promoting and leveraging model multi-party agreements to enable trust and thus facilitate exchange. Membership is open to any individual or organization that has an interest in furthering the mission including vendors, HIE’s, provider organizations as well as individuals. CAHIE works cooperatively with other eHealth efforts and we are narrowly focused on enabling trust and technology to facilitate HIE-to-HIE exchange.

George McNeil, IT Officer with Nevada Health Link, (previously the Silver State Health Insurance Exchange) was kind enough to take some time out of his day to sit down with Rob Waters, Program Director with Healthcare IT Connect to discuss the governance, operational and IT implementation at the exchange, as George and his team push to remain on schedule for the October 1st launch.

Rob Waters: Could you explain to our readers about the governance structure of Nevada Health Link? And has this affected the IT roadmap for the exchange implementation?

George McNeil: Nevada Health Link is governed by an Appointed Board. The board consists of seven voting members and 3 non-voting state officials. The Exchange is an independent State Agency formed to oversee the creation of Nevada’s state-based insurance marketplace (Nevada Health Link). The Exchange has partnered with Xerox State Healthcare, LLC. This partnership has allowed us to move at a very quick pace. States have had a very short time frame to create the State Based Exchanges and Nevada has been able to leverage our partner’s solution, knowledge and resources to meet these short timelines.

RW: Shopping for health insurance via a web portal is a new experience for the vast majority of consumers, what are some of the best practices that Nevada Health Link has applied to make the user’s experience simple, intuitive and efficient?

GM: Nevada Health Link’s web portal will employ many consumer tools to help with selecting the best plan for themselves and their family. The smart application is one of these features, if an individual appears eligible for Advance Premium Tax Credits or for Medicaid, the application will ask more questions to confirm eligibility. If a person does not wish to apply for either of these programs, they will be able to answer a much smaller set of questions and move directly into the shop and compare module. The consumer cost calculator on our shop and compare pages allows an individual to simulate use of the plan throughout the year. Consumers will be able to plug in the anticipated amount of doctors office visits, specialist visits, emergency room visits, prescription drugs and generic drugs to get a feeling of what the plan will cost them over the course of the year based on their usage. Consumers will also be able to select up to three plans and compare each plan side by side to look for differences in coverage, formularies and financial information such as deductibles and co-pays. If a consumer has questions or concerns, they can always us our web chat, email or customer service call center to get an answer right away. Although purchasing health insurance online is not as easy as booking a flight, Nevada Health Link is putting technology in place to make it easy to understand and find the coverage that is right for you.

RW: What has been the process for the Nevada Health Link to ensure Insurance Carriers are able to successfully participate in the exchange?

GM: The Exchange engaged insurance carriers in the state in early 2012. Over the first half of 2013 the Exchange conducted Carrier Onboarding sessions to outline all of the requirements in terms of application, technological requirements, reporting, network adequacy, marketing and appeals. Anthem, Health Plan of Nevada, Nevada Health CO-OP and St. Mary’s have filed Qualified Health Plans to be sold on Nevada Health Link this October.

RW: Given that HIX technology implementation is going to be slightly different from state to state, have there been opportunities for Nevada to leverage the experiences and technology components from other states to implement the exchange?

GM: As I stated earlier Nevada has partnered with Xerox State Healthcare LLC. We are implementing a Software as a Service (SaaS) system. The system has undergone a number of changes to both make it compliant with the Affordable Care Act and Nevada Revised Statutes. We do meet with other states on a normal basis to discuss experiences but we have not been able to really leverage their technology components.

RW: Protecting confidential consumer information at the exchange has to be a top priority, what provisions have been taken to mitigate against these risks at the exchange and for information shared with other HHS agencies?

GM: The Exchange will only collect the minimum information required to achieve its mission. The Exchange portal and supporting systems employ industry best practices for security, confidentiality and auditing with emphasis on federal and state information safeguards. Each Exchange is also required to undergo two distinctively separate security reviews from the IRS and the Centers for Medicare and Medicaid Services. The Exchange must past these reviews before certification will be allowed.

EngagePoint was recently awarded the prime contract for Missouri’s Human Services’ IT transformation efforts, David Smith is Engagepoint’s executive sponsor providing oversight for the project. David sat down with Rob Waters, Program Director with Healthcare IT Connect to take a deeper dive on some of the implementation goals, deliverables as well as the opportunity for Missouri to benefit from similar systems EngagePoint is designing in Arkansas, Minnesota and Maryland.

ROB WATERS: David, can you explain your role as the executive sponsor for the State of Missouri project. Is this unique to Missouri and why is the role important?

DAVID SMITH: Simply put, my role as executive sponsor is to see that the overall objectives of the state are achieved and the needs of all its constituents are met – not just for the immediate project, but to assure that the solution we’re developing has the capability, the flexibility to support the needs of the state and its citizens for the long term.

RW: Can you tell us about EngagePoint’s experience working with other states on their HIX and Medicaid transformation? What have been some of the lessons learned, technology transfers that MO could benefit from?

DS: EngagePoint is working with five states in roles ranging from architecting, designing and implementing new health insurance marketplaces, to modernizing Medicaid eligibility systems, to, in one case, providing implementation support directly to that state’s integrated project management office.

One key benefit EngagePoint brings is the experience and expertise we’re continuously accumulating. We’re able to leverage our understanding and knowledge and bring the methodologies and artifacts that have already been created. It comes down to reusability. By being able to reuse artifacts, code, methodology, processes, and governance models, we’re able to reduce the time to implement solutions that address current needs with a flexible, sustainable platform that will be able to support future requirements.

RW: Can you give us an overview of the work that EngagePoint will be doing with MO as the systems integrator and who are the other major vendors involved?

DS: Our role as system integrator is to provide the foundation on which the entire solution is built and which enables all of the individual components or COTS products to work together seamlessly – to interoperate and perform as a single solution – for citizens to determine eligibility and enroll in the state’s social services programs.

For the state of Missouri, the key components we’re bringing together are IBM’s Cúram software for Medicaid eligibility determination, a Medicaid plan presentment and selection solution, and EngagePoint Financials for Medicaid premium billing and reconciliation.

RW: From an operational perspective, what is EngagePoint putting in place to support the contract. Are there specific governance and management models you’re following?

DS: We are able to re-use proven methodologies and models from other projects. Project governance is key, and we have developed a governance model that provides the state visibility, traceability, and accountability for all decisions.

RW: Is there a specific methodology or approach that EngagePoint has found to be more effective for fixed scope, fixed timeline projects of this type?

DS: If there’s a common theme here, it’s “reusability.” Reusability is key. Being able to leverage our knowledge and work from other projects enables EngagePoint to reduce the time to deliver. It’s what’s allowing us to meet these aggressive timelines.

RW: Once States have completed major build projects in support of E&E, case management and data sharing, how do you envisage they will begin to utilize this infrastructure to serve citizens improve care coordination as reform is implemented?

DS: The legacy systems we’re replacing in many cases are more than 25 years old. Most operate in a mainframe environment. They don’t allow real-time interaction for citizens or caseworkers to access information, get answers to their questions, or determine eligibility.

We see states leveraging the infrastructure we’re developing to improve their efficiency, effectiveness, and the quality of service they’re delivering. Ultimately we see states leveraging this infrastructure to empower individuals through self-service models that offer rapid access to information, answers to their questions, and the ability to directly enroll in the program they’re eligible for.

Rob Waters, Director of Program Development with HITC, this week connected with Dan Burton, CEO, Health Catalyst to discuss Partners Healthcare’s recent $1 million investment.

Dan serves as CEO and Board Member at Health Catalyst, a nationally recognized leader in healthcare data warehousing and analytics, headquartered in Salt Lake City, Utah.

Rob Waters: Partners HealthCare recently made a $1 million equity investment in Health Catalyst, what does this mean for Health Catalyst and how does Partners benefit as an investor?

Dan Burton: Health Catalyst has found great value in developing deep relationships with its clients. The relationship with Partners includes three dimensions, all of which contribute to a genuine partnership: first, there is a significant commercial relationship—Partners has selected the Health Catalyst Data Warehouse as its enterprise-wide data platform. Second, Partners and Health Catalyst have entered into a co-development relationship where we are committed to co-developing analytic applications that run on top of the data warehouse platform. And third, Partners has become an investor in Health Catalyst, which aligns our organizations and deepens the relationship further.

Rob Waters: Other large health systems such as Kaiser Permanente and Indiana University have also made equity investments, was this always part of Health Catalyst’s strategy to co-develop value-added applications on top of Health Catalyst’s Enterprise Data Warehouse (EDW)?

Dan Burton: This is a fundamental part of Health Catalyst’s strategy–we have found that the best partnerships we have developed have been with our client health systems, particularly those who are recognized leaders nationally. We will soon be adding health system clients to the list of co-development partners, and we are grateful for the deep relationships we have with IU Health and Kaiser on the investment side.

Rob Waters: Partners HealthCare is certainly recognized as a national leader in delivering accountable and coordinated care to help drive down costs, are there any specific projects that both organizations felt would immediately benefit from applying Health Catalyst’s technology and why were they selected?

Dan Burton: We are still finalizing what applications we will co-develop, but there is a high likelihood that our co-development efforts will tap into the deep experience Partners has gleaned from being one of the nation’s largest ACOs. We are excited about the applications that will be developed through this partnership that will likely be relevant to every ACO and population health effort in the country.

Rob Waters: What are some of the timelines for establishing EDW and beginning to build applications at Partners?

Dan Burton: We just kicked off the EDW implementation project in June, and we expect meaningful achievements by the end of this year. We will be kicking off co-development work this fall, and would expect meaningful products developed by the first half of 2014

Rob Waters: You recently announced the introduction of Health Catalyst 2.0, how can customers such as Partners leverage some of these improvements?

Dan Burton: Partners will be deploying all of the latest advances to the Health Catalyst platform as part of our EDW deployment, and we expect all of our health system clients to leverage these new benefits very soon—they are all entitled to these advances through their maintenance and support contracts, and we are excited to facilitate the migration to this advanced platform in the months ahead.

Dan Burton became involved as an investor and as the business leader of Health Catalyst when it was a three-person startup. Since that time Health Catalyst has realized triple-digit annualized revenue growth, expanded its platform reach to over 20 million patients, and dramatically increased its employee base, product line and access to capital. Investors include Sequoia Capital, Norwest Venture Partners, Sorenson Capital, HB Ventures, Kaiser Permanente Ventures, Partners HealthCare, and CHV Capital.

Mr. Burton has held positions such as CEO, President, Board Member and Chief Marketing Officer with a number of other small-to-midsize companies affiliated with HB Ventures, helping to enable these organizations to realize growth and success. He is also the co-founder of HB Ventures, the original investor in Health Catalyst. Prior to Health Catalyst and HB Ventures, Mr. Burton led the Corporate Strategy Group at Micron Technology. He also spent eight years with Hewlett-Packard in strategy and marketing management roles, including building and managing a technology infrastructure business. Before joining HP he was an associate consultant with the Boston Consulting Group, where he advised healthcare systems and technology companies. Mr. Burton holds an MBA with high distinction from Harvard University, where he was elected a George F. Baker Scholar, and a BS in economics, magna cum laude, from BYU.

Health Catalyst provides a transformational approach to healthcare analytics and data warehousing. Catalyst deploys a unique Late-Binding™ Data Warehouse that enables healthcare organizations to automate extraction, aggregation and integration of clinical, financial, administrative, patient experience and other relevant data and apply advanced healthcare analytics to organize and measure clinical, patient safety, cost and patient satisfaction processes and outcomes. Developing this information management capability is crucial to shifting to evidence-based care required to succeed under the new shared accountability models of value-based purchasing and risk payment models such as ACOs.

Rob Waters, Director Program Development with Healthcare IT Connect caught up with Todd Rothenhaus, Chief Medical Officer with athenahealth to discuss population health management and what it takes for providers to be successful in the ACO marketplace.

Todd has been with athenahealth since April 2011, and is a nationally recognized expert on the implementation of electronic health record systems and the use of information technology in support of effective and accountable care. Prior to joining athenahealth, Dr. Rothenhaus was CIO of Steward Health Care (formerly the Caritas Christi), the second largest health system in New England.

Rob Waters (RW): Todd, since ARRA’s HITECH Act was implemented in 2008 to help practices implement EMRs many new programs have rolled out by CMS to help providers deliver more accountable care, how have these programs impacted your customers needs overall and how has athenahealth responded to these needs?

Todd Rothenhaus (TR): I think the first part of the question is what programs? I think we saw an immediate change up from what we had for ‘meaningful use’ in a cash for clunkers deal where suddenly people spent millions and billions on IT systems to meet ‘meaningful use’ yet were completely unprepared for the needs of executing and succeeding under accountable care. So while the original idea was that we were going to put computers in front of everybody and they were going to magically change things, we found that EHRs in of themselves are completely inadequate for solving core issues around population health management. The stimulus program wasn’t long sighted enough to push this industry forward, and now there is a need for new capabilities.

RW: Clinical integration is one of the first steps for providers to participate in new care delivery models such as ACOs and PCMH. Does athenahealth support providers with this strategic planning component?

TR: Yes, absolutely and in fact going back to your earlier question, what we found at athenahealth is that the customer’s needs have just not been met by the current crop of EHRs. Practices need a strong foundation in traditional revenue cycle. They need to be able to gain some margins so that they can start to begin to pay for all the initiatives that they need to launch under PCMH, or an accountable care umbrella. There is no better time now to clean up fee for service, and it’s the first step. The second step is looking at your office and asking yourself are you even ready to take on anything new? The example that I like to give is you go to the dentist and he or she has five hygienists, 25 chairs, and there is a factory working that’s able to very quickly see people. Then you walk to a physician’s office and there is one guy, one MA and three rooms, and the place is jammed up and they have no way of getting people in and out. There is some substrate of clinical performance getting people in and out, contacting them and working them between visits, that needless to say is what we call healthcare. We have gone from a 1:10 ratio of doctors compared to everybody else in the health system now to 1:15. We’ve got negative productivity in healthcare and we need to fix that and we need to fix that at a micro level.

It’s got nothing to do with EHRs in that you have glorified word processors that people were selling as the first generation of EHRs. There is workflow support that needs to happen. If you take that one step further and things are financially stable, and you are performing because you can get people in and out efficiently and you can contact them and work with the between visits. Now you can concentrate on clinical effectiveness and I don’t think that the industry has responded well here. We have got a lacklustre performance in meaningful use. Meaningful use is identical to any other pay performance program. They are all numerators, denominators exclusions, and if you can’t get meaningful use what hope can you have in managing quality as part of an ACO.

RW: Performance data transparency is often viewed as a critical component of improving both clinical and financial performance amongst ACO participants. Is this an area you are tackling?

TR: Absolutely. The first step toward data transparency is that every primary care doctor in America has patients who access caregivers in other spots and they don’t know about it all. Every health system in America has patients who seek care elsewhere, here in Massachusetts we have got a provider organization at which 65% or 70% of the dollar cost of care of their patients is delivered by a competitor, and so those organizations need to basically capture market share. They have always had to, and they still need to do it. These organizations would probably rather pay themselves as opposed to paying a competitor for services that they can deliver under a risk-based contract and so that level of transparency is only obtained when you got a complete picture of what has been paid for the patient. This type of administrative claims data represents a foundational layer of data access for executing on a contract. The other piece of data transparency is once you have decided that you want to reduce utilization. We are not seeing a hospital system too anxious to reduce utilization, but we are seeing our independent medical groups in a perfect position to reduce utilization. Once you are ready to do that providers need to be able to shop and what I mean by that is they should make the referral from labs, radiology department, and other physicians. They ought to be able to see how much that person charges and what those costs are and how the quality is and again getting that data and having that delivered to the point of care is what we are doing here at athenahealth.

RW: Many providers are also looking at the opportunity to integrate claims and clinical data into the analytics tool set. At what stage should they be doing that and should every ACO be looking to achieve that in a relatively short amount of time?

TR: I deeply believe that if an organization is actively managing patients in a risk-based contract that the next dollar they spend should not be on anything but understanding the total cost and the total picture of the population health through the claims based analysis. If they don’t have that, they can’t succeed. No amount of other technology will help them succeed. I believe that the addition of clinical data to the claims data assets is an essential next step, but I think that sucking data out of antiquated EHR systems that are under the desk of a doctor’s office or in a data center is a really nasty business. I am hopeful that there will be some standards based integration solutions that will help them do this without breaking the bank. We at athenahealth of course support standards based interfaces for free, but asking us to suck data out of the backend of another EHR, it isn’t necessarily a best use of everybody’s money. So, the first dollar must go to claims, the second dollar to clinical data.

RW: Cloud computing platforms are often referenced by leading health IT vendors is away to help providers deal with the myriad of healthcare data required for improved clinical and business decision making. What makes athenahealth’s offering different and how does this impact your customers ability to succeed in the new transformed healthcare?

TR: Well, that’s a great question=. We are in the cloud and we consider that now an unfair advantage as we compete against other vendors with a traditional software model. First and foremost the costs of IT are the next enormous bond burden that non-profit hospitals are carrying. They are spending extraordinary amounts on information technology without any link to outcomes.The cloud offers a truly more economical solution to any healthcare IT project. Most of the start ups you see in healthcare today are cloud-based to some degree because nobody is building technology in a traditional software model. Yet,legacy EHRs that are out there and are in use have never been ported and probably won’t be ported to the cloud.

Our ability to help our clients succeed is really based on the fact that they are all on the exact same instance of our cloud-based solution, and that we are able to provide them insights as to how they are performing down to the minutia. For example, we know exactly how long every doctor on athenaNet, our cloud-based network, takes to complete a chart. We know exactly how many days an average doctor has in his inbox of labs and radiology studies that he or she needs to review after they’ve ordered them during a patient visit. So that transparency that we are able to create and the fact that we can join them in the work of taking work out of the practice is what we consider comparative advantage in the 21st century. Doctors, nurses, and other care providers shuffling work off to lower cost people who should be performing that work, like Medical Assistants. So there is this way of basically insulating the clinician who is really the only billable unit in a medical group and who has studied for 8 to 10 years from having to do what’s commonly referred to as scut work and that makes it a better way. It’s life changing for physicians to not have to fill out all those administrative forms that they used to have to fill out.

RW: As the healthcare industry moves away from fee for service and payers and providers collaborate around shared saving and other risks based models (ACOs and PCMH), What do you see are the biggest challenges over the next five years for providers to attain those savings you know, required for these models to be successful and to become predominant?

TR: That’s a great question, we are already seeing some of the pioneer ACOs start to complain that it was too hard and are thinking about leaving that program so this is a very timely question. I really think there are two things that will separate. I do think attention to tools is a critical component. I think that if people think that EHRs plus HIEs are going to solve the nation’s healthcare problems and help them succeed under risk that they are wrong. We now have a new industry of population health management tools that everybody needs to use, too and, unfortunately, I think there are those who are stuck thinking that their $100 million or $500 million investment in a hospital EHR is the solution. They are in fact wrong. The second component is really the timing, understanding the way the money works and timing the intervention. Timing the tactical execution in the contract. I see organizations all over the country that are instituting care management as the first step towards accountable care and what they are really doing is adding cost. Unless they are in a risk-based contract it is very hard to capitalize on the reduction in utilization to come. So there is a proper order of doing this and I think that very few people understand it. CFOs need to start grabbing the reins a bit back and saying, we’ve got to look at this contract and understand how to tactically execute it and in what order should we be doing things. This way CFOs can spend money reducing the utilization early on alone but still manage quality and coordinate care effectively as an initial step.